Friday, November 25, 2011

Thousands of Texas doctors, researchers and medical experts — including more than 100 who are employed by the state and are paid with taxpayer dollars — routinely supplement their salaries with income from pharmaceutical companies.

Drug companies pay medical professionals for a wide range of activities, from speaking engagements to consulting. While legal, the practice raises questions about potential conflicts, and whether the interests of patients may be compromised.

From 2009 to early 2011, at least 25,000 Texas physicians and researchers received a combined $57 million — and probably far more — in cash payments, research money, free meals, travel and other perks, according to data culled from 12 drug companies and provided by the nonprofit investigative news organization ProPublica.

Dozens of these medical professionals were paid more than $100,000 each during that period. And 114 were professors, physicians, psychiatrists or researchers who were already paid a salary by the state — in some cases more than a half-million dollars a year. These state employees brought in nearly $3 million combined from pharmaceutical companies from 2009 to early 2011, according to a Texas Tribune analysis of the ProPublica data.

Nationwide, pharmaceutical manufacturers routinely pay medical professionals to assess a new product or to help contribute to the drug company's sales. The companies fly medical professionals to seminars and conferences and may also pay speaking fees. State-employed doctors and researchers are generally no exception, though they are supposed to comply with their individual institutions' conflict-of-interest policies.

"It's important to state out of the gate the importance of these interactions, the value they bring to physicians, to health care professionals in general and ultimately to patients," said Karl Uhlendorf, vice president of Pharmaceutical Research and Manufacturers of America.

But the financial relationships raise questions about the influence of drug companies on prescribing patterns or research results. The practice "puts patients and tax dollars at risk," said Lee Spiller, the policy director for the Texas branch of the Citizens Commission on Human Rights, a nonprofit mental health watchdog. "It taints the whole process. I'd hate to think donations were shaping state mental health policy in particular."

Dr. Stanley Self, a part-time psychiatrist at Texas' state-run Rusk psychiatric hospital, earns $166,000 a year from the state. He also earned at least $145,000 from drug companies in 2009-10, largely for speaking engagements. Dr. Self did not return calls seeking comment on his work for drug companies, but his receptionist said he is "not doing much of that anymore."

Christine Mann, a spokeswoman for the Department of State Health Services, said agency employees, like Dr. Self, are allowed to hold a second job as long as there is not a conflict of interest. The agency "is looking into this issue further and will examine its policies to see if there are provisions that need to be strengthened," Ms. Mann said.

Dr. Joseph Bailes, an oncologist and the vice chairman of the executive committee at the Cancer Research and Prevention Institute of Texas, earned roughly $250,000 between 2009 and 2010 as a consultant for Pfizer. Dr. Bailes said that he has advised Pfizer on Medicare policy — not on drug development — and that it has no bearing on his role with the institute, a $3 billion endeavor financed by voter-approved bonds, for which he is an "unpaid volunteer" specializing in efforts to bring new cancer therapies to market.

"It doesn't influence anything I do," Dr. Bailes said, adding that his committee is not responsible for selecting projects for financing.

Dr. Stanley Lemon, who left his post as the director of the Institute for Human Infections and Immunity at the University of Texas Medical Branch in April and is now at the University of North Carolina, made nearly $80,000 consulting for Pfizer in 2009-10. Dr. Lemon, who is still an adjunct professor at U.T.M.B. but is no longer on the state payroll, said consulting for the pharmaceutical industry has enriched his academic life and made him a more productive scientist.

"As long as they are properly reported and do not engender conflicts of interest or commitment, such interactions between industry and academia help to move drug development forward in a positive way," Dr. Lemon wrote in an e-mail.

The analysis of Texas pharmaceutical payments comes as the state attorney general's office prepares for a mammoth trial in January against Janssen Pharmaceuticals and its parent company,Johnson & Johnson. Janssen, which has vigorously denied any wrongdoing, has been accused of offering trips and kickbacks to state health officials to get the schizophrenia drug Risperdal on an approved drug list for medications that are paid for by the state.

Across the country, the reporting of such perceived conflicts has traditionally fallen short. Companies have not been required to disclose payments, and medical institutions have made limited efforts to police their employees.

The ProPublica data covers just a part of drug company payments — it represents about 40 percent of the 2010 pharmaceutical market in the United States — and includes manufacturers that have either begun disclosing their payments voluntarily, or as a result of legal settlements.

Beginning in March, federal law will require drug and device companies to report and disclose all of their payments to medical professionals and researchers; by September, the data is supposed to be displayed in a searchable online government database. Texas universities — whose doctors and researchers account for $2.7 million of the pharmaceutical money statewide from 2009 to early 2011 — are working to update their own conflict policies and monitoring systems.

The University of Texas System will require its faculty members to report every dollar they are paid by a drug or device manufacturer and all financial interests in their research beginning Jan. 1.

The U.T. Southwestern Medical Center in Dallas is working on an electronic conflict-of-interest filing system that will feed into a soon-to-be-released public disclosure Web site, said Tim Doke, U.T.-Southwestern's vice president for communications.

"We've been working feverishly here for the last couple of months," Mr. Doke said. "Transparency is the absolute key to the public being confident that conflicts that exist are being managed appropriately."

At the University of Texas MD Anderson Cancer Center in Houston, university administrators monitor drug company databases to ensure that faculty-conflict filings match, and to set limits on how much doctors and researchers can accept, said Dr. Raymond DuBois, the center's provost and executive vice president.

But such efforts at transparency vary widely depending on the institution, or may be nonexistent when there is no institution at all. State records show that of the 74 doctors and psychiatrists statewide who have routinely prescribed the highest number of costly antipsychotic drugs to patients on Medicaid, the joint state-federal health insurance program for the disabled, children and the very poor, 10 received payments from drug companies in 2009-11 — from $11,000 to $180,000 each.

All but one got the payments from the maker of the drug they most commonly prescribed.

Beeps and blinking lights are the constant chatter of a hospital intensive care unit, but at the I.C.U.'s in North Shore University Hospital in Manhasset, N.Y., the conversation has some unusual contributors. Two L.E.D. displays adorn the wall across from each nurses' station. They show the hand hygiene rate achieved: last Friday in the surgical I.C.U., the weekly rate was 85 percent and the current shift had a rate of 91 percent. "Great Shift!!" the sign said. At the medical I.C.U. next door, the weekly rate was 81 percent, and the current shift 82 percent.

That's too low for a "Great Shift!!" message. But by most standards, both I.C.U.'s are doing well. Those L.E.D. displays are very demanding — health care workers must clean their hands within 10 seconds of entering and exiting a patient's room, or it doesn't count. Three years ago, using the same criteria, the medical I.C.U.'s hand hygiene rate was appalling — it averaged 6.5 percent. But a video monitoring system that provides instant feedback on success has raised rates of hand-washing or use of alcohol rubs to over 80 percent, and kept them there.

Hospitals do impossible things like heart surgery on a fetus, but they are apparently stymied by the task of getting health care workers to wash their hands. Most hospitals report compliance of around 40 percent — and that's using a far more lax measure than North Shore uses. I.C.U.'s, where health care workers are the most harried, usually have the lowest rates — between 30 and 40 percent. But these are the places where patients are the sickest and most endangered by infection.

How do hospitals even know their rates? Some hospitals track how much soap and alcohol gel gets used — a very rough measure. The current standard of care is to send around the hospital equivalent of secret shoppers — staff members who secretly observe their colleagues and record whether they wash their hands. This has serious drawbacks: it is expensive and the results are distorted if health care workers figure out they're being observed. One reason the North Shore staff was so shocked by the 6.5 percent hand-washing rate the video cameras found was that measured by the secret shoppers, the rate was 60 percent.

In the past few years, several new technologies have emerged that can help hospitals to measure and improve hand hygiene rates. I've written in Fixes about some hospitals that have tried them and found good results. But medicine pays attention only when there are studies in a peer-reviewed journal, and there hasn't been one — until now. The North Shore study, published this week in the journal Clinical Infectious Diseases, is the first use of video in promoting hospital hand-washing, and the first controlled study in a peer-reviewed journal of a high-tech effort to increase hand hygiene rates.

Dr. Bruce Farber, the head of infectious diseases at North Shore, says that hospitals are now willing to take extraordinary and expensive measures to prevent infection — but this attitude is new. If he had proposed experimenting with video cameras a few years earlier, he said, he might have met with a lot of resistance. But he found none. "I don't think there's any pushback in terms of people thinking this is a real problem and we need to do things," he said. "The next crux is: what works and what doesn't work?"

There is an overwhelming need to find out. About 1 in 20 hospital patients becomes ill with an infection — many or most of them from the hands of health-care workers. Hospital-acquired infections are the fourth leading cause of death in America. Add up annual deaths in the United States from car accidents, AIDS, and breast cancer, and they are still lower than the 100,000 deaths each year from hospital-acquired infection.

Recently, hospitals have been given a financial incentive as well. In 2008, Medicare began to stop reimbursing hospitals (nor are hospitals allowed to bill patients) for the cost of treating some hospital-acquired infections, and the list is expanding every year. The health care reform bill does the same with Medicaid, and insurance companies are beginning to follow. Treating these infections is hugely expensive — the average cost is at least $15,000. These infections cost somewhere between $28 billion and $45 billion a year.

I wrote earlier about hospitals trying a sensor system: health care workers get a badge that sniffs alcohol — an ingredient in hand sanitizer and hospital soap. The sensor can tell when the worker last washed hands. If the worker crosses a perimeter around a patient and hasn't washed his hands, the system beeps to remind him.

North Shore instead uses a video monitoring system made by a company called Arrowsight. Cameras on the ceiling are trained on the sinks and hand sanitizer dispensers just inside and outside patient rooms. (Patients are not photographed.) A monitor at each door tracks when someone enters or leaves the room — anyone passing through a door has 10 seconds to wash hands. Arrowsight employees in India monitor random snippets of tape and grade each event as pass or fail.

What makes the system function is not the videotaping alone — it's the feedback. The nurse manager gets an e-mail message three hours into the shift with detailed information about hand hygiene rates, and again at the end. The L.E.D. signs are a constant presence in both the surgical and medical I.C.U.s. "They look at the rates," said Isabel Law, nurse manager of the surgical I.C.U.. "It becomes a positive competition. Seeing "Great Shift!!" is important. It's human nature that we all want to do well. Now we have a picture to see how we're doing."

Data on infection rates was not in the journal article, but Dr. Farber said that rates of MRSA (resistant staph, one of the most deadly and expensive superbugs) have dropped.

The development of Arrowsight's technology shows the evolution in hospitals' thinking about hand hygiene. This is Arrowsight's first foray into health care. The company's main business is meat: half the beef processing plants in America use its video system to monitor workers' hygienic practices.

Adam Aronson, Arrowsight's chief executive, said that at one plant cameras focused on a hand sanitizer dispenser right outside the bathroom. With monitoring and feedback, hand hygiene rates went from about 4 percent to over 95 percent, and the achievement was sustained.

Aronson showed the results to his father, Mark David Aronson, a professor at Harvard Medical School. His father told him that 3,000 people die every year of the food-borne illnesses the cameras in meat plants were trying to prevent — but 100,000 die of hospital-acquired infections. "You have a civic duty to try to get this into hospitals," his father said.

Aronson met with 10 hospitals; no one was interested, and he gave up.

Then five years ago, Aronson's mother and sister both contracted serious infections in hospitals: his sister nearly died of infection after giving birth, and his mother contracted a bone infection that has left her with a permanent limp. He decided to try again. One of his employees had an uncle who ran a tiny surgery center in Macon, Ga. "It had very low rates of hand hygiene — and we got them over 90 percent within weeks," he said. Then he approached North Shore.

At first Farber feared he wouldn't be able to get approval; the conventional wisdom was that employees don't like being videotaped. But then he thought about a recent experience at the dry cleaner: he had picked up some of his daughter's clothes, but one of her suits was missing. He went back to the shop and told them the date and approximate time of his visit. They pulled up a video that indeed showed him leaving her suit behind. "If dry cleaners are doing that, we need to do that in the hospital," he thought.

North Shore got a $50,000 grant from the New York State health department to install the system in the 18-bed medical I.C.U.; the hospital pays the $1000 monthly maintenance. Because it was an academic study, North Shore decided not to reward or punish individual workers, for fear it might contaminate the results. The "Great Shift!!" on the L.E.D. sign is the only reward. North Shore later put the system into the surgical I.C.U. as well. Now another hospital, the University of California San Francisco Medical Center, has installed the system.

Like the other high-tech hand hygiene systems, Arrowsight's is expensive. But if low-tech isn't working, it's a good investment — it will pay for itself if it prevents two or three infections.

It is now nearly four years since the cameras went in to North Shore, and hand hygiene rates remain high, although higher in the surgical I.C.U. than the medical I.C.U.. William Senicola, the nurse manager of the medical I.C.U., said one reason for the difference was that there had been an emergency with a patient that morning, which gave the staff other priorities. "It has to do with volume," he said. He said that three months into the program, one of the nurses on his staff called him on a Saturday morning at home. She told him that she had gotten up to go to the bathroom in the middle of the night and banged into the wall as she automatically reached for the alcohol gel dispenser she expected to find. "That's a real change in culture," he said. "That's when we knew we were there."

Tuesday, November 22, 2011

The scientific panel tasked with sorting out the conflicting signals on breast-cancer screening has only inflamed the debate and left women – and their doctors – even more confused.

New guidelines, written by the Canadian Task Force on Preventive Health Care, are designed to clarify best practices for screening at a time when many experts and advocacy groups remain sharply divided, particularly about the benefits of routine mammograms for women in their 40s.

The controversy – playing out against the backdrop of a strapped health-care system that has to make hard decisions about resources and costs – has been stirred by the new national screening recommendations, which say Canadian women under age 50 who are at an average risk of developing breast cancer should not have routine mammograms, and that also advises against self-exams at any age.In addition to limiting mammograms to women age 50 to 74, the guidelines also say clinical breast exams and self-exams have no benefit and shouldn't be used; that women aged 50 to 69 should have mammograms every two to three years, instead of every year or two; that women aged 70 to 74 should have mammograms every two to three years – previous guidelines didn't recommend screening for that age group.

The recommendations don't apply to women with an elevated risk of breast cancer, such as those with a history of the disease in a first-degree relative or those with mutations in the BRCA1 and BRCA2 genes.

But instead of quelling debate, the recommendations are opening a new chapter in the simmering battle.

While many oncologists and groups such as the Canadian Cancer Society say the new recommendations, published Monday in the Canadian Medical Association Journal, are a balanced approach that will focus breast cancer screening programs on women who can benefit most, others believe the move to limit mammograms to those age 50 and over will put lives in danger.

"We're really disappointed to see these recommendations," said Sandra Palmaro, CEO of the Canadian Breast Cancer Foundation, Ontario region. "They're ultimately going to result in more women dying from breast cancer that don't need to be dying from breast cancer, there's no question."

Provinces are responsible for breast cancer screening programs. Many, such as British Columbia, Alberta and Nova Scotia, regularly give mammograms to women aged 40 to 49, while some others, including Ontario and Newfoundland and Labrador, do not. It remains to be seen whether provinces choose to adopt the new guidelines.

At the heart of the debate is an argument about the merits of cancer screening programs. Proponents of mammograms for women in their 40s say they can save lives by detecting cancer early.

But more recently, the tide has been shifting away from the notion that more screening is better. For instance, a U.S. panel ruled in 2009 that women in their 40s should not be screened for breast cancer. The backlash from advocacy groups and experts was so fierce that the rules haven't been adopted.

Last weekend, the screening controversy showed up in the medical journal The Lancet, which published a letter signed by more than 40 physicians and radiologists, including three Canadians, who detect an "active anti-cancer screening campaign" among a particular group of scientists. The campaign, they say, is marked by "erroneous interpretation of data from cancer registries and peer-reviewed articles."

Still, more experts in Canada have begun questioning whether support for screening programs has been too zealous, responding to growing scientific evidence suggesting that mammograms for women aged 40 to 49 may not save many lives, but can lead countless women to have unnecessary follow-up treatments and biopsies.

"I think we're in a situation where there's been question marks about screening mammography," said Eitan Amir, medical oncologist at Princess Margaret and Mount Sinai hospitals in Toronto.

A Danish study published in the British Medical Journal last year, for instance, found little difference in breast cancer mortality rates among women who had routine mammograms and those who did not.

Using evidence from previously conducted studies, the Canadian Task Force on Preventive Health Care found that more than 2,100 women aged 40 to 49 would need to be screened regularly for an 11-year period to prevent one breast cancer death. At the same time, it would cause nearly 700 women to have a false-positive mammogram result and needless follow-up, with 75 of those women having an unnecessary biopsy. For women aged 50 to 69, the number needed to be screened to prevent one breast cancer death is 721.

Despite shifting evidence, it will be difficult to change the dialogue because the perceived benefits of mammography have become ingrained, experts say. Compounding the problem is the fact that some advocacy groups and medical experts continue to publicly champion the notion of more screening at earlier ages, which may confuse women.

"Certainly there's always going to be groups that try to sensationalize this stuff," said Gillian Bromfield, director of cancer control policy at the Canadian Cancer Society. "I think it is concerning when we scare women into screening, no matter what their age."

After driving hundreds of miles, the last thing Roy Williams, a truck driver from Denton, Tex., wanted to do was exercise. After a day trapped in the cab, stopping only to gorge on greasy fare at truck stops, who could think of working out?

But once he ballooned to 405 pounds, he knew he had to make a change. So last year, Mr. Williams, 58, did something all too rare for someone in his profession: He embarked on a diet and exercise program.

The six-pack of Coca-Cola he drank each day? Gone. The hamburgers, chips and chocolate he relished? No more. Today, he drinks a protein shake mixed with ice water or soy milk for breakfast, nibbles cantaloupe and red grapes, and makes "sandwiches" with thinly sliced meat and cheese but no bread. He keeps a fold-up bike in his truck and zips around rest areas on his breaks.

His weight is down to 335 pounds, and he's managed to reduce the amount of blood pressure medication he takes. "I rarely, maybe once a week, even go into a truck stop," said Mr. Williams, who has been navigating an 18-wheeler for the last 30 years.

Mr. Williams's predicament is hardly unique. On the road for weeks on end, with the sorts of diets that make nutritionists apoplectic, the nation's truckers are in pretty bad shape. Now, beset by rising insurance costs and desperate to ensure their drivers pass government health tests, trucking companies and industry groups are working hard to persuade road warriors to change their habits.

It's a long haul, so to speak. Eighty-six percent of the estimated 3.2 million truck drivers in the United States are overweight or obese, according to a 2007 study in The Journal of the American Dietetic Association.

"Obesity is a terrible problem in the trucking industry," said Brett Blowers, director of marketing and development for the Healthy Trucking Association of America, an industry organization in Montgomery, Ala.

A few years ago, Mr. Blowers's group conducted a blood pressure screening of more than 2,000 drivers at an annual truck show. "We sent 21 directly to the emergency room, and one of them had aheart attack on the way there," he recalled.

It's a problem not just for truckers, but for anyone who shares the road with them. In 2010, heavy and tractor-trailer truck drivers accounted for 13 percent of all fatal occupational injuries, according to preliminary data from the Bureau of Labor Statistics. A 2007 report from the Federal Motor Carrier Safety Administration found that 87 percent of crashes involving truckers stemmed to some degree from driver error. Twelve percent of these cases were because the driver was asleep, had a heart attack, was in diabetic shock or had some other health problem.

"Of the accidents that are preventable, I'd say about 10 to 25 percent, if not higher, were from drivers who were tired, had sleep apnea or were not physically fit," said Chad Hoppenjan, director of transportation safety services at Cottingham and Butler, an insurance broker in Dubuque, Iowa.

The United States Department of Transportation requires drivers to pass a certifying medical exam every two years. Drivers are checked for severe heart conditions, high blood pressure and respiratory maladies, including sleep disorders.

While the statistics are bleak, they're not especially surprising. Driving is a sedentary activity. Most truckers are paid by the mile, so they tend to squeeze out every last second of the 11 hours they're allowed on the road in a 24-hour period.

"Some days I've driven 600 miles and didn't even stop," said Barb Waugh, 58, of Fairfax, S.D., one of an estimated 190,000 female truckers. In a typical week she logs 2,500 to 4,000 miles. "I feel like a marshmallow because I don't get to exercise," said Ms. Waugh, who weighs about 300 pounds.

Routines that keep other Americans healthy — hitting the gym, cooking at home, scheduling a doctor's appointment — are nearly impossible, since drivers are rarely in one place for more than a day or two. The only exercise for many is pressing the gas pedal; most don't load and unload cargo.

When they do leave their vehicles, it's usually at truck stops and fast-food restaurants where nearly every option is greasy or fatty or served up in calorie-rich buffets — which some truckers say stands for "Big Ugly Fat Fellows Eating Together."

Jill Garcia, 50, a driver from San Antonio who is obese and has sleep apnea and hypertension, said: "I swear, the truck stops have a candy-a-holic at their corporate offices. You can get two king-size bars for $3. I got four packs of M&M's for a buck."

Until recently, few in the transportation industry cared to tackle its health issues. "When you tried to talk to someone to connect the dots, they looked at you like you had three heads," said Bob Perry, founder of Rolling Strong, which offers health and wellness programs for truckers.

Now transportation carriers, industry organizations and even truck stops are unrolling initiatives to help truckers slim down, shape up and improve their health. Employers are holding health seminars, building on-site gyms, bringing in nutritionists and fitness trainers, and offering financial incentives to employees who stop smoking or lose weight. Some drivers are cooking in their rigs, walking or bike riding around truck stops, blogging about their experiences at sites like truckingsolutionsgroup.org and safetythruwellness.com, and writing books.

Lindora Clinic, which operates weight-loss centers, last year unveiled "Lean for Life On-the-Road," a nutrition and exercise program for the trucking community. The company has teamed up with the Truckload Carriers Association, which represents 400 carriers, for a "Trucker Weight Loss Showdown" to begin in January. For two and a half months, 10 fleets, each composed of six drivers and six office workers, will exercise and follow low-carb, low-fat, moderate-protein diets.

This year, TravelCenters of America/Petro unrolled a program called StayFit, which includes fitness rooms, mapped walking trails and healthier foods at its stops. Snap Fitness, an international chain of 24-hour gyms, has announced plans to open a workout facility at one, and perhaps many more, of the 550 Pilot Flying J Travel Centers across the country.

While concern for driver health is certainly a force behind the wellness initiatives, economics also plays a role. The trucking industry is grappling with sky-high insurance rates and rising medical costs. The 2010 Cottingham and Butler Trucking Compensation and Benefits Benchmark Survey, an annual report for the trucking industry, found that deductibles and out-of-pocket costs to truck drivers and their employers are 40 percent to 70 percent higher than in other industries.

"It just keeps going and going, and you don't know how to control it," said Sidney Brown, chief executive officer of NFI, a logistics company in Cherry Hill, N.J. To help cut costs, his company has started quarterly wellness newsletters, free smoking cessation workshops, discounts with WeightWatchers and Anytime Fitness, and a companywide "Biggest Loser" competition.

The industry also is struggling to retain veteran drivers while recruiting new ones. According to Debbie Sparks, vice president of development for the Truckload Carriers Association, the industry is short about 150,000 drivers, and she expects that number to rise to 300,000 by next year. But nearly 40 percent of new drivers quit within their first 90 days.

"We've got to make ourselves more attractive to recruit a new generation of truck drivers," said Ms. Sparks.

Some of these programs have had modest success. Con-way Freight, based in Ann Arbor, Mich., has hired 46 full-time wellness coaches who rotate among 110 facilities. The company has seen a 32 percent reduction in workdays lost to injury, said Bob Petrancosta, its vice president of safety.

Several years ago, Trucks Inc., a regional carrier in Jackson, Ga., shifted to an annual Department of Transportation physical rather than bi-annual. It has since saved more than $250,000 in medical insurance costs diagnosed several pre-heart attack and pre-diabetic conditions among drivers. And a sleep apnea treatment program at Schneider National, based in Green Bay, Wis., has saved the company $651 per driver per month in health care costs since its inception in 2003.

Still, it's likely to be a long time before truckers are clamoring for steamed tofu and doing Sun Salutations at rest stops. "Unless the driver is scared to death for their life, unless they've had a medical event, they're probably not going to change," said Michael Metzger, 37, whose Web site, Healthy Trucker Lifestyle, chronicles his weight-loss experience (70 pounds and counting) and offers recipes and exercise tips for drivers.

"You've got to go to them, and you've got to speak their language," said Mr. Perry of Rolling Strong. "They truly don't want to be told what to do — they have to feel that they're making this decision on their own."

When the Lindora Clinic started working with truck drivers, recalled Cynthia Stamper Graff, the company's executive chairwoman, she often received beleaguered phone calls. "The drivers said: 'I don't think we can do this. This is too difficult,' " she recalled. "The challenges of life on the road — no structure, not being at home where you have a refrigerator, no proper food choices. And they weren't exercising."

But slowly, she said, drivers embraced the company's 10-week program, which includes weekly phone consultations with a "nurse coach" and costs $360 a person, often paid wholly or in part by the employer. So far, the 75 drivers who have completed the program have shown an average loss of 8.4 percent from their starting weight.

Mr. Johnson signed up with Lindora this summer after hitting 226 pounds. Beforehand, his only exercise was "walking into the truck stop restaurant, eating a bit and going back to the truck," he said.

Today he weighs about 208 pounds, and his truck doubles as a makeshift gym. He does sit-ups inside the trailer and pull-ups below. He fills a cooler with 60 pounds of ice and lifts it over his head 10 to 15 times. He power-walks around truck stops, some of which cover four or five acres, though he balks at the idea of using the area around his truck as a running track (32 laps around a rig is a mile, drivers are sometimes reminded).

"That's just goofy," he said.

Some drivers have even turned to private trainers. Kevin Melton, 39, a trucker in Black Mountain, N.C., used to snack on Snickers bars and three or four Little Debbie pies a day while driving. His weight shot to 260, his joints and back ached, and his cholesterol was "through the roof."

Two years ago, he began working with Chadwick Slagle, a trainer. Together they devised a nutrition plan: Mr. Melton now eats five meals a day, drinks water instead of soft drinks, and snacks on fruit and nuts. He wakes up at 4:30 a.m. to exercise, running on a treadmill or around a parking lot. He now weighs about 200 pounds and hopes to get down to 190.

He has had to rethink some of his beliefs. "You hear Snickers are healthy because of the nuts, that they give you energy," he said. "But when you read the label you realize they're surrounded by caramel."

For Ms. Garcia, who recently joined WeightWatchers, a new lifestyle was an easy decision. She takes medication for high blood pressure, and she worries that the day will come when she won't pass her physical.

"I'm being stupid if I don't lose the weight," she said, "because I'll lose my job."

My friend's mother got terrifying news after she had a mammogram. She had Stage 0 breast cancer. Cancer. That dreadful word. Of course she had to have surgery to get it out of her breast, followed by hormonal therapy.

Or did she?

Though it is impossible to say whether the treatment was necessary in this case, one thing is growing increasingly clear to many researchers: The word "cancer" is out of date, and all too often it can be unnecessarily frightening.

"Cancer" is used, these experts say, for far too many conditions that are very different in their prognoses — from "Stage 0 breast cancer," which may be harmless if left alone, to glioblastomas, brain tumors with a dismal prognosis no matter what treatment is tried.

Now, some medical experts have recommended getting rid of the word "cancer" altogether for certain conditions that may or may not be potentially fatal.

The idea of cancer as a progressive disease that will kill if the cells are not destroyed dates to the 19th century, said Dr. Otis Brawley, chief scientific and medical officer at the American Cancer Society. A German pathologist, Rudolph Virchow, examined tissue taken at autopsy from people who had died of their cancers, looking at the cells under a light microscope and drawing pictures of what he saw.

Virchow was a spectacular artist, and he ended up being the first to describe a variety of cancers — leukemia, breast cancer, colon cancer, lung cancer.

Of course, his patients were dead. So when he noted that aberrant-looking cells will kill, it made sense. The deranged cells were cancers, and cancers were fatal.

Now, Dr. Brawley said, the situation is very different. Instead of taking tissue from someone who died, a doctor takes tissue from a living patient, threading a thin needle into a woman's breast or a man's prostate, for example. Then a pathologist looks for abnormal cells.

Yet "how it looks under a microscope," Dr. Brawley said, "does not always predict." That is especially true for things like Stage 0 breast cancer or similar conditions in other areas of the body — conditions detected by screening and not by symptoms or by feel.

Researchers have come to appreciate this conundrum.

"The definition of cancer has changed," said Dr. Robert Aronowitz, a professor of history and sociology of medicine at the University of Pennsylvania.

Many medical investigators now speak in terms of the probability that a tumor is deadly. And they talk of a newly recognized risk of cancer screening — overdiagnosis. Screening can find what are actually harmless, if abnormal-looking, clusters of cells.

But since it is not known for sure whether they will develop into fatal cancers, doctors tend to treat them with the same methods that they use to treat clearly invasive cancers. Screening is finding "cancers" that did not need to be found. So maybe "cancer" is not always the right word for them.

That happened recently with Stage 0 breast cancer, also known as ductal carcinoma in situ, or D.C.I.S. It is a small accumulation of abnormal-looking cells inside the milk ducts of the breast. There's no lump, nothing to be felt. In fact, Stage 0 was almost never detected before the advent of mammography screening.

Now, with widespread screening, this particular diagnosis accounts for about 20 percent of all breast cancers. That is, if it actually is cancer. After all, it is confined to a milk duct, has not spread into the rest of the breast, and may never spread if left alone — it might even go away.

It could also break free and enter the breast tissue. But for now, it is hard to know in many cases whether it makes any difference to treat D.C.I.S. right away or to wait to see if it spreads, treating it then.

Two years ago, an expert panel at the National Institutes of Health said the condition should be renamed. Get rid of the loaded word "carcinoma," the panel said. A carcinoma is invasive; D.C.I.S. has not invaded the breast. If those cells do invade, they are no longer D.C.I.S. Then they are cancer. So call the condition something else, perhaps "high-grade dysplasia."

The word "cancer" is so powerful it overwhelms any conversation about what Stage 0 breast cancer actually is, said Cynthia Pearson, executive director of the National Women's Health Network. When women contact her group to ask about cancer treatments, "sometimes we're well into the conversation with them before it comes out that they don't actually have an invasive cancer."

The pathologist Donald Gleason, who invented Gleason scoring for prostate tumors, wanted to rename a very common tumor — the so-called Gleason 3 + 3 — "adenosis" instead of cancer, Dr. Brawley said. His idea was that by calling a 3 + 3 "cancer," men and their doctors would feel they had to get rid of it right away.

Despite Dr. Gleason's wishes, 3 + 3 cells are still called cancer. And despite the panel's advice about D.C.I.S., that name has not changed either.

Cervical cancer specialists had better luck. In 1988, they changed the name of a sort of Stage 0 of the cervix. It had been called cervical carcinoma in situ. They renamed it cervical intraepithelial neoplasia, Grades 1 to 3, taking away the cancer connotation.

But Dr. Brawley, for one, has not given up on educating doctors and patients about the general inadequacy of the word "cancer." As he put it, "The movement is not quite dead."

It often takes a crisis, major or minor, to prompt people to change bad habits, especially when the change is time-consuming and anxiety-provoking.

The other day, the drawer in which I store my swimming stuff jammed. When I finally got it open and dumped out its contents, I counted more than a dozen bathing suits (several with their store tags intact), 12 bathing caps, 10 pairs of goggles and countless nose clips and earplugs.

Then I recalled the same thing had happened a week earlier with my drawer of pens and pencils, literally hundreds of them, half of which were dried out or otherwise useless.

And I shouldn't even mention my full-size freezer or humongous medicine cabinet, where things fall out every time I open them. Or my floor-to-ceiling plastic bins of yarn, mountain-high pile of Bubble Wrap, bags of plastic bags and shopping bags, and shelves of items I thought might be gifts for someone someday.

Having just read "Homer & Langley," E. L. Doctorow's novel about the Collyer brothers, who were found dead in a Harlem brownstone under more than 100 tons of stuff they had accumulated, I finally vowed to tackle my lifelong tendency to accumulate too much of nearly everything and my seeming inability to throw out anything that I considered potentially useful to me or someone else sometime in the future.

Living in a three-story house with full basement made it far too easy to pursue this habit. I had plenty of storage space (and had filled every nook and cranny of it), but often couldn't find things when I needed them, including clothes, books, articles, even frozen food I knew I had stored somewhere. Last year I found eight unopened jars of cocktail sauce in the back of my fridge; I had forgotten I had any and kept buying more.

When a product I liked at the moment was on sale (graham crackers, lipstick, shampoo, detergent, cereal, supplements), I often bought as many as I could and added them to already overflowing stashes. I'm often afraid I won't be able to get more when I need it, a concern occasionally validated when a manufacturer discontinues something I like. But more often, I tire of these items and move on to others long before I've used up the old purchases.

Steps to Declutter

Recently, as if by fate, an advance copy of a book arrived in the mail that is without doubt the most helpful tome for anyone with a cluttering tendency. It's called "The Hoarder in You: How to Live a Happier, Healthier, Uncluttered Life" (published Tuesday by Rodale Books). It was written by Robin Zasio, a clinical psychologist, a star of the show "Hoarders" and director of the Anxiety Treatment Center in Sacramento.

I would say that Dr. Zasio's book is about the best self-help work I've read in my 46 years as a health and science writer. She seems to know all the excuses and impediments to coping effectively with a cluttering problem, and she offers practical, clinically proven antidotes to them.

Unless you are an extreme hoarder (the kind portrayed on the show) who requires a year or more of professional therapy, the explanations and steps described in the book can help any garden-variety clutterer better understand the source of the problem and its negative consequences, as well as overcome it and keep it from recurring.

Though it is not possible here to include all of Dr. Zasio's lessons, here are a few I think are especially helpful.

Perhaps most important is to tackle just one project at a time and stick with it until it is done. "Start with the easiest, and be proud of what you've done," Dr. Zasio said in an interview. Then gradually move on to more challenging projects.

Schedule time for decluttering — say, an hour each day on most days, until you're done.

There's no question that parting with stuff you've collected and thought valuable can trigger anxiety. But, as Dr. Zasio says and I have found, the anticipated anxiety is usually worse than what actually ensues. Even if it is acute, the anxiety dissipates if you sit down or do something fun or relaxing until it passes.

Make three piles (or bins) of stuff: Keep, Donate, Discard. (Avoid my mistake of making a fourth pile called Undecided that you simply wind up moving to another part of the house.) Get rid of the Discard and Donate piles as soon as possible. Keep only those things that have a realistic "home" in your home.

Dr. Zasio admits to owning 175 pairs of shoes, but, she said, "they're neatly arranged, and I have access to them all."

I've found it easiest to part with clothes, shoes and jewelry I no longer wear if I give them to people I know can use them. But anonymous giving to organizations like Goodwill or Vietnam Veterans of America is satisfying, too.

Strategies to Maintain

I have particular difficulty resisting "buy one, get one free" offers, half-price sales and bulk-purchase "bargains" in big-box stores. Think first about where the products will go and how many of them you already have. These sales and bargains will repeat themselves, and you'll get other opportunities. If necessary, stop reading sale fliers and cancel your membership at Costco.

"Ultimately, if you never get to use it, a sale item may end up costing you more than you save," Dr. Zasio said.

Keep in mind that, like food and medications, beauty products have expiration dates, so buying more than you'll need in the near future can be wasteful. "It's O.K. to have one backup, but do you really need 10?" Dr. Zasio asked.

Bring nothing new into the house unless you have a proper place for it. "If you can't identify a place for it to live, it probably should not come home," she said.

In clearing my own clutter, I realized my late husband — who often asked me, "How many rolls of paper towels and toilet paper do you really need?" — had collecting problems of his own. I uncovered old cans of paint, picture frames and books he found on the street, all manner of wood, boxes of chipped crystal, every version of every song and show he ever wrote (he was a lyricist and playwright), and bags of our twin sons' memorabilia since preschool (they're now 42).

By cleaning out his stuff and my own, I will spare my children a horrible task when I'm gone. And when I stop wasting time accumulating, storing, searching for and moving around stuff I really don't need, I might have time for a new companion: a dog.

On Jessica Haley's 28th birthday in June, she posted a wish on the fund-raising Web site IndieGoGo. Ms. Haley and her husband, Sean, of Melbourne, Fla., wanted a baby, but their insurance did not cover fertility treatment.

To their astonishment, donations started pouring in. Word of the couple's plight spread on Twitter and Facebook, and a "Help the Haleys Have a Baby" campaign raised $8,050 — including $423 from a total stranger.

"It was miraculous — I can barely talk about it still," Ms. Haley said. "It was this hidden community that lifted us up and was helping us through this really difficult time."

Online fund-raising — a common tactic for nonprofit groups and charity events — is starting to spread to the world of costly health care. Although some Web sites do not accept such personal appeals (Ms. Haley's was rejected by the first site she tried), dozens of health-oriented campaigns have appeared on IndieGoGo in recent months.

They cover a wide range of needs, from small medical expenses to extensive cancer treatments and even organ transplants. The family of a man with Parkinson's disease is trying to raise money to offset the costs of his care. In Florida and Texas, families are trying to raise money to cover costs for two men with advanced colon cancer. Friends of a 26-year-old Brooklyn man who suffered a spinal cord injury are seeking $25,000.

Posting to IndieGoGo is free, but the site takes 4 percent of the money raised. (To encourage users to set reasonable goals, the site imposes a 9 percent fee if a campaign falls short of the fund-raising goal.) Slava Rubin, who helped found IndieGoGo in 2008, says successful health-oriented campaigns on the site now number in the "hundreds."

For Mr. Rubin, 33, it is a personal matter. He was just 15 when his father died of multiple myeloma. He uses the site himself for Music Against Myeloma, an annual charity event, as well as other cancer fund-raising campaigns.

"We created a funding platform that was purposefully very open, so when people used it for personal health it wasn't shocking to us," he said. "I think health care issues and personal health campaigns make sense, because our health care system can be very expensive sometimes. Sometimes people just need to try a different direction to get funded what they need to get funded."

To prevent fraud, the site requires campaign sponsors to provide information about their bank account, and it uses a fraud algorithm to detect suspicious activity. But ultimately, Mr. Rubin said, it is "the crowd" that decides if a cause is legitimate.

Most campaigns will not get off the ground without initial support from family and friends. Most campaigns receive about 80 percent of donations from networks of friends, and friends of friends, while about 20 percent of the donations come from strangers.

Last winter, Jeffery Self, a 24-year-old actor and writer in Los Angeles, broke a tooth that later became infected and required at least $3,400 in dental surgery and repair. Lacking insurance, he feared he would lose a newly booked acting job because he could not afford to fix his tooth.

But after seeing friends raise money online to support independent films and music, Mr. Self made a humorous video for IndieGoGo, appealing for $1 and $2 donations for dental work. ("Hi, my name is Jeffery Self," he begins with a snaggle-toothed smile, "and I didn't always look like this.") To his surprise, he raised $3,650.

"I said, 'I know this is really weird crazy and strange, but I'm desperate and I need your help,' " he explained in an interview. "People want to use the Internet for good. We are so oversaturated with bad stuff on the Internet, when the opportunity comes to help each other out, I think it's nice to do it."

Daniel Weiss, a filmmaker and writer in Maui, Hawaii, has created slide shows and videos for IndieGoGo health fund-raisers to help several of his friends. It started when he heard of a friend's 7-year-old niece with macular degeneration who wanted to see London and Paris before losing her sight. The campaign raised $5,075 toward travel costs.

"They might lose their home, but even if we don't meet our goal it will certainly help them in their situation," said Mr. Weiss, who says he does not charge for his services. "It's astonishing and heartwarming to feel the compassion coming from a complete stranger."

Ms. Haley says the downside of public fund-raising is the requirement to discuss her private struggles with infertility. Several women posted their own supportive stories, although a few people criticized her for not pursuing adoption. (Ms. Haley said she and her husband had not ruled it out.)

While most donors were friends or friends of friends, she said, about 20 percent appeared to be total strangers.

Recently, Ms. Haley returned to her IndieGoGo page, but not to raise more money. This time she posted news: She is pregnant. Mr. Rubin, the site's co-founder, now refers to the event as "the first crowd-funded baby."

"I cried millions of times that day out of pure excitement and joy," Ms. Haley said. "It was amazing to get all that support through a computer."